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An alarming increase in AMR? Irrational use of antibiotics, overdosing or under-dosing, self-medication and the inappropriate use of antimicrobials in a hospital setting are all to blame

A young man barges into the air-conditioned pharmacy nearly sneezing his nose off. “Give me something for a headache/cold,” he tells the pharmacist as he wipes his runny nose on his sleeve.

“Do you have fever?” the pharmacist asks.

“No,” he replies.

After a brief conversation — one that you might have expected the young Turk to have had with his GP — the pharmacist gives him a long list of antibiotics, an antihistamine and a blister pack of antacids. He pays, gets a glass of water from the kind pharmacist, pops a tablet of each drug into his mouth, gulps them down and walks out, wiping his face on his sleeve again.

You could wish and hope that this is a rare scenario, but the truth is that it’s pretty common across the country. The pharmacists, oh well, the folks who man the pharmacy — with or without a qualifying degree — are, verily, doctors, dispensing advice and medicines with equal glee. The first rule of antibiotic use is that they are used to fight bacterial infections and they don’t work on viruses. A common cold or cough is most likely caused by a viral infection. In the young man’s case, a course of antibiotics has been used in vain.

Reality of AMR

It is precisely this kind of carpet-bombing of the community with antibiotics that is responsible for the alarming increase in antimicrobial resistance (AMR) in the country. Irrational use of drugs, overdosing or under-dosing, self-medication, misuse of drugs, and the inappropriate use of antimicrobials in a hospital setting are all cause for alarm.

Dr. Abdul Ghafur, Consultant, Infectious Diseases And Clinical Microbiology, Apollo Hospitals, Chennai, was in the small team of professionals who put together the “Chennai Declaration”, which has come to be recognised as a sort of milestone for activities against antimicrobial resistance in India.

Growing antibiotic resistance has been well-documented in the recently released National Treatment Guidelines for Antimicrobial Use in Infectious Diseases (for medical professionals) that the Centre drew up. The report articulates the urgent need to follow guidelines: “Antimicrobial resistance in disease pathogens has become a matter of great public health concern globally.” Attributing it to the widespread use and availability of practically all antimicrobials across the counter for human and animal consumption, it sets out clear dividing lines for doctors to follow.

“The ‘Chennai Declaration’ created awareness among the medical fraternity about the need to control antibiotic usage. Of course, it could be argued that we should have taken action on this at least a decade earlier,” says Dr. R. Ramasubramanian, consultant, Infectious Diseases, and Director, Immune boosters, Adult Immunisation clinic at Apollo Hospitals, Chennai. The NDM-1 superbug scare played a key role in getting at least hospitals to wake up to the issue. However, he points out, the thing about this is that it is not rocket science, and only requires a change in mindset, among doctors and patients. Prescribing antibiotics for common viral infections, pharmacists selling antibiotics over the counter and a few precautions for hospital-based workers — using a hand rub before and after examining the patient, for instance — will go a long way in controlling the spread of resistant bugs, as well as hospital-acquired infections.

Measuring load

Giridhar Gyani, founder Director General of the newly constituted Association of Healthcare Providers (India), was earlier involved with hospital standards in his avatar as the secretary general, Quality Council of India. He suggests that measuring the antimicrobial load of every State is the way ahead. “While Kerala has already made some headway in this, once each State starts measuring the load then there is no escaping the reality of AMR.”

But headway seems to have been made on that front. Recently, the Union Health Ministry launched the National Programme for AMR Containment. Among its key tasks is to conduct AMR surveillance with a network of 10 laboratories across the country. It has begun to generate data from various sites. In fact, it is this data that helped form the guidelines for treatment, Dr. Ghafur explains. Which is why the guidelines will be constantly evolving. They will take into account the latest trends and data to indicate better treatment for various infections, he adds.

But what does a person keen on avoiding developing bacterial resistance do? Is it even possible for an individual to take on the big bugs’ resistance and emerge unscathed? Guidelines are for the professionals, anyway.

“Basic information that antibiotics are effective only with the bacterial infections should help,” he says. This knowledge will make an informed, if, at times, pesky patient. Checking with the physician if the antibiotic is absolutely essential, and not buying drugs without prescriptions are some of the tricks patients can learn, even as they defer to the superior knowledge of the doctor involved.

In food chain

Even if the utmost care is taken to keep off unnecessary antibiotics, Dr. Ramasubramanian points out the enormity of use in non-human subjects, animals and poultry. In terms of tonnage, human use versus animal use of antibiotics is nearly 1:5. When you eat chicken dosed in this way with antibiotics, it fills your gut and colonises it, leaving you vulnerable when you are actually ill and need to take drugs to counter an infection. In other words, you have turned resistant to certain drugs, thanks to the consumption of chicken dosed with antibiotics.

Dr. Ghafur explains that antibiotics are used to “wash out” livestock of any kind of bacteria, not only to treat diseases but also to prevent them, and in the process spur faster growth. The tough part is that the practice is rather widespread across the world, and it has actually become tough to touch animal products that are “safe”. There are, however, free-range animal products that claim to be free of antibiotics, but are difficult to verify, and are expensive too.

During the first World Antibiotic Awareness Week (WAAW) in November last, Danilo Lo Fo Wong, Programme Manager for Antibiotic Resistance at WHO/Europe, said, “What we must do — as policy-makers, health-care workers, patients and farmers — is to ensure effective treatment for as long as possible through the rational use of antibiotics.”

In a world without borders, the only way we will get there is for every country in the nation to go “rational” at least while writing out prescriptions.

ramya.kannan@thehindu.co.in

Some key facts about AMR

Antibiotic resistance occurs when bacteria become resistant. When they infect humans, then the infections become harder to treat.

It is not a problem only for people who take antibiotics regularly. Even those who do not, when infected by a resistant bug, are difficult to treat.

Antibiotics are used to treat bacterial infections. They do not work with virus-causing infections as colds and flu.

Do not self-medicate with antibiotics.

What was prescribed the last time by a doctor may not be right this time.

Do not take drugs that were prescribed for someone else with similar symptoms.

The pharmacist is not a doctor, he/she cannot prescribe any drugs, certainly not antibiotics. Prescriptions are absolutely essential.

Do not press for antibiotics for common infections.

You can ask the doctor if an antibiotic is required, if it seems you have only a cold or cough. (There can be secondary bacterial infections over viral infections, so let the doctor be the judge of that)

Do not underdose or overdose. Complete the entire course of antibiotics that the doctor has prescribed, even if you feel better before.

Build immunity, to prevent frequent infections, by eating healthy, drinking plenty of fluids, exercising well, and washing hands properly before meals, and after using the toilet.

Antibiotics are used in humans and animals in the proportion 1:5. In terms of percentage of total antibiotics manufactured used, the latter is significantly higher. However, there are livestock products in the market that claim to be antibiotic-free. So look for such a label if you want to avoid this element.

Fertilizers made up of animal faecal matter that contains antibiotics may be used on food crops too.